1. The school nurse is preparing a presentation for an elementary school teacher to inform

them about when a child should be referred to the school clinic for further follow-up.

The teachers should be instructed to report which situations to the school nurse?

(Select all that apply)

a. Refuses to complete written homework assignments

b. Thirst and frequent requests for bathroom breaks

c. Bruises on both knees after the weekend

2. When preparing a child for discharge from the hospital following a cystectomy and a

urinary diversion to treat bladder cancer, which instruction is most important for the

nurse to include in the client’s discharge teaching plan?

a. Report any signs of cloudy urine output

b. Frequently empty bladder to avoid distention

c. Follow instructions for self-care toileting

d. Seek counseling for body image

3. A client with renal lithiasis is receiving morphine sulfate every four hours for pain and

renal colic. Which assessment finding should prompt the nurse to administer PRN dose

of naloxone?

a. Unresponsive to verbal or tactile stimuli

b. Respiratory rate of 12 breaths per minute

c. Statements about visual hallucinations

d. Complaints of increasing flank pain

4. The mother of a 7-month-old brings the infant to the clinic, because the skin in the

diaper area is excoriated and red, but there are no blisters or bleeding. The mother

reports no evidence of watery stools. Which nursing intervention should the nurse

implement?

a. Instruct the mother to change the child’s diaper more often

b. Encourage the mother to apply lotion with each diaper change

c. Ask the mother to decrease the infant’s intake of fruits for 24 hours

d. Tell the mother to cleanse with soap and water at each diaper change

5. The nurse is having difficulty palpating a client’s posterior tibial pulse while the client is

lying in a supine position. Which of the following interventions is best for the nurse to

take?

a. Extend the client’s arm fully while supporting the elbow and attempt to repalpate

b. Apply less pressure when palpating over the middle of the dorsum of the foot

c. Use an ultrasound stethoscope, and place behind and below the medial bone

d. Help the client to a prone position with the knee slightly flexed and palpate again

6. The nurse initiates a tertiary prevention program for type 2 diabetes mellitus in a rural

health clinic. Which outcome indicates that the program was effective?

a. Average client scores improved on specific risk factor knowledge tests

b. Only 30% of client did not attend self-management education sessions

c. More than 50% of at-risk clients were diagnosed earl in the disease process

d. Sunburn with blisters on face, arms, and hands

e. Shaking that changes the child’s handwriting

d. Client who developed disease complications promptly received rehabilitation

7. A client is recovering in the critical care until following a cardia catheterization. IV

nitroglycerin and heparin are infusing. The client is sedated but responds to verbal

instructions. After changing positions, the client complains of pain at the right going

insertion site. What action should the nurse implement?

a. Stimulate the client to take deep breaths

b. Evaluate the integrity of the IV insertion site

c. Assess distal lower extremity capillary refill

d. Check femoral site for hematoma formation

8. A 7-year old is admitted to the hospital with persistent vomiting, and nasogastric tube

attached to low intermittent suction is applied. Which finding is most important for the

nurse to report to the healthcare provider?

a. Shift intake of 640mL IV fluids plus 30mL PO ice chips

b. Serum pH of 7.45

c. Serum potassium of 3.0 mg/dl

d. Gastric output of 100 mL in the last 8 hours

9. A morbidly obese client is scheduled for gastric bypass surgery. The client completes the

required preoperative nutritional counseling and signs the operative permit. To

promote effective discharge planning, which intervention is most important for the

nurse to implement?

a. Discuss small, low fat, low sugar meal preparation techniques

b. Advise the client to arrange for dietary counseling after being discharged

c. Encourage the client to keep a daily diary for two weeks

d. Suggest that the client’s spouse do the family grocery shopping

10. The nurse is admitting a client from the post-anesthesia unit to the postoperative

surgical care unit. Which prescription should the nurse implement first?

a. Cefazolin 1-gram IVPB q6 hours

b. Complete blood cell count (CBC) in AM

c. Straight catheterization if unable to void

d. Advance from clear liquid as tolerated

11. Which needle should the nurse use to administer IV fluids via c lient’s implanted port?

a. 5cc syringe & needle

b. Butterfly stick

c. **click on the image that isn’t any of the other options**

d. Vacutainer

12. An older client is referred to a rehabilitation facility following a cerebrovascular accident

(CVA). The client is aphasic with left-sided paresis and is having difficulty swallowing.

Which intervention is most important for the nurse to include in the client’s plan of

care?

a. Use pictures and gestures to communicate

b. Arrange for daily home care assistance

c. Facilitate a consultation for speech therapy

d. Initiate passive range of motion exercises

13. A client has had several episodes of clear, watery diarrhea that started yesterday. What

action should the nurse implement?

a. Assess the client for the presence of hemorrhoids

b. Administer a prescribed PRN antiemetic

c. Check the client’s hemoglobin level

d. Review the client’s current list of medications

14. A mother runs into the emergency department with a toddler in her arms and tells the

nurse that her child got into some cleaning products. The child smells of chemicals on

hands, face, and on the front of the child’s clothes. After ensuring the airway is patent,

what action should the nurse implement first?

a. Call poison control emergency number

b. Determine type of chemical exposure

c. Obtain equipment of for gastric lavage

d. Assess child for altered sensorium

15. When should the nurse conduct an Allen’s test?

a. Prior to attempting a cardiac output calculation

b. When pulmonary artery pressures are obtained

c. Just before arterial blood gasses are drawn peripherally

d. To assess for presence of deep vein thrombosis in the leg

16. A nurse with 10-years’ experience working in the emergency department is reassigned

to the perinatal unit to work an 8-hour shift. Which client is best to assign to this nurse?

a. A mother with an infected episiotomy

b. A client who is leaking clear fluid

c. A client at 28-weeks’ gestation in pre-term labor

d. A mother who just delivered a 9-pound baby

17. A 300mL unit of packed red blood cells is prescribed for a client with heart failure (HF)

who has 3+ pitting edema, shortness of breath with any activity, and cracked in both

lung bases. At what rate should the nurse administer the blood?

a. 150 mL/hour

b. 75 mL/hour

c. 300 mL/hour

d. 50 mL/hour

18. The nurse enters the room of the client with Parkinson's disease who is taking carbidopa

levodopa. The client is arising slowly from the chair while the unlicensed assistive

personnel (UAP) stands next to the chair. What action should the nurse take?

a. Tell the UAP to assist the client in moving more quickly

b. Offer PRN LG 6 to reduce painful movement

c. Affirm that the client should arise slowly from the chair

d. Demonstrate how to help the client move more efficiently

19. Which assessment is more important for the nurse to include in the daily plan of care for

a client with a burnt extremity?

a. Range of motion

b. Distal pulse intensity

c. Extremity sensation

d. Presence of exit exudate

20. Client is receiving continuous ambulatory peritoneal dialysis since the arteriovenous

graft in the right arm is no longer available to use for hemodialysis. The client has lost

weight, has increasing peripheral edema, and has a serum albumin level of 1.5 g/ dL.

Which intervention is the priority for the nurse to implement?

a. Instruct the client to continue to follow the prescribed rigid fluid restriction

amount

b. evaluate pat and see of the AV graft for resumption of hemodialysis

c. ensure the client receives frequent small meals containing complete proteins

d. recommend the use of support stockings to enhance venous return

21. An older adult client with systemic inflammatory response syndrome (SIRS) has a

temperature of 101.8 F (38.8 C), heart rate of 110 beats/minute, and a respiratory rate

of 24 breaths/minute. Which additional finding is most important to report to the health

care provider?

a. Capillary glucose reading of 110 mg/dL (6.1 mmol/L SI)

b. serum creatine of 2.0 mg/dL (176.8 micromol/L SI)

c. Hemoglobin of 12 g/dL (120 g/dL SI)

d. blood pressure of 134/88 mm hg

22. the nurse completes auscultation of the thoracic region of an older adult client. Which

finding is considered normal for this older adult client?

a. High pitched wheezing

b. Hyperresonance

c. medium crackles

d. vesicular sounds

23. a client who is admitted for primary hypothyroidism has early signs of myxedema coma.

In assisting the client, in which sequence should the nurse has completes these actions?

(Rank the first action at the top with the remainder in descending order)

Step 1. observe breathing patterns

Step 2. assess blood pressure

Step 3. measure body temperature

Step 4. palpate for pedal edema

24. What is the primary goal when planning nursing care for a client with degenerative joint

disease (DJD)?

a. achieve satisfactory pain control

b. obtain adequate rest and sleep

c. improve stress management skills

d. reduce risk of infection

25. the home care nurse provides self-care instructions for a client with chronic venous

insufficiency caused by deep vein thrombosis. Which instructions should the nurse

include in the client's discharge teaching plan? (Select all that apply)

d. maintain the bed flat while sleeping

a. Avoid prolonged standing or sitting

b. use recliner for long periods of sitting

c. continue wearing elastic stockings

e. cross legs at knees but not at ankles

26. One hour after a lung biopsy, a client returns to the surgical unit. The client is drowsy

but easily aroused and follows commands accurately. Which intervention is most

important for the nurse to implement?

a. Encourage range of motion exercises

b. notify family of the client's return to the room

c. reinforce use of incentives spirometry

d. offer fluids if gag reflex is intact

27. An older woman who was recently diagnosed with end stage metastatic breast cancer is

admitted because she is experiencing shortness of breath and confusion. The client

refuses to eat and continuously asks to go home. Arterial blood gases indicate hypoxia.

Which intervention is most important for the nurse to implement?

a. Prepare for emergent oral intubation

b. offer sips of favorite beverages

c. clarify end of life desires

d. initiate comfort measures

28. the health care provider prescribed the antibiotic Cefdinir 300 mg PO every 12 hours for

a client with a postoperative wound infection. Which foods should the nurse encourage

this client to eat?

a. Yogurt and/or buttermilk

b. avocados and cheese

c. green leafy vegetables

d. fresh fruits

29. a client with cirrhosis of the liver is having numerous, liquidy, incontinent stools and

continues to be confused. In review of the client's laboratory studies, the nurse

identifies an elevated serum ammonia level. Based on this finding, which prescription is

the most important for the client to receive?

a. Loperamide

b. IV human albumin

c. Lactulose

d. Furosemide

30. After a routine physical examination, the HCP admits a woman with a history of

Systemic Lupus Erythematous (SLE) to the hospital, because she has 3+ pitting ankle

edema and blood in her urine. Which assessment finding warrants immediate

intervention by the nurse?

a. Blood pressure 170/98

b. joint and muscle aches

c. urine output of 300 mL/hr

d. dark, rust colored urine

31. the nurse is preparing a client with an acoustic neuroma for a magnetic resonance

image (MRI). which client complaint is life threatening and should be reported to the

health care provider immediately?

a. Intensifying headache

b. facial numbness

c. difficulty with balance

d. right ear hearing loss

32. **too blurry for me to see this question**

33. An unresponsive male victim of a motor vehicle accident is brought to the emergency

department where it is determined that immediate surgery is required to save his life.

The client is accompanied by a close friend, but no family member is available. What

action should the nurse take first?

a. Ask the man's friend to sign the informed consent since the client is

unresponsive

b. notify the unit manager that an emergency court order is needed to allow the

surgery

c. continue to provide life support until a thorough search for a guardian is

completed

d. carry on with the surgical preparation of the client without a signed informed

consent

34. a young adult female with chronic kidney disease (CKD) due to episodes of

pyelonephritis is hospitalized with basilar crackles and peripheral edema. She is

complaining of severe nausea and the cardiac monitor indicates sinus tachycardia with

frequent premature ventricular contractions. Her blood pressure is 200/100 mm Hg, and

her temperature is 101 F. Which PRN medication should the nurse administer first?

a. Enalapril

b. Furosemide

c. Acetaminophen

d. Promethazine

35. **Picture of a mannequin with NG tube inserted with tape still on the face** The nurse

assesses a client who has just returned from a diagnostic study, as seen in the picture.

The client has a prescription for a nasogastric tube to low intermittent suction and

reports feelings of nausea. What action should the nurse implement first?

a. Remove tape from cheek

b. administer an IV antiemetic

c. auscultates bowel sounds

d. connect the tube to suction

36. following breakfast, the nurse is preparing to administer 0900 medications to clients on

a medical floor. Which medication should be held until a later time?

a. The mucosal barrier, sucrafalta (CARAFATE), for a client diagnosed with peptic

ulcer disease

b. the antiplatelet agent Aspirin, for a client who is scheduled to be discharged

within an hour

c. the antifungal Nystatin suspension for a client who has just brushed his teeth

d. the loop diuretic Furosemide, for a client with a serum potassium level of 4.2

mEq/L (4.2 mmol)

37. A client with a history of upper respiratory symptoms is admitted with chest tightness, a

productive cough, and difficulty breathing. The clients arterial blood gases indicate

respiratory acidosis. An increase in which laboratory test results supports this finding?

a. Arterial pH

b. PaCO2

c. HCO3

d. PaO2